Science Has No Sex
Page 28
All in all, then, Zakrzewska seemed intent on fashioning a hospital around a radical social agenda, whether by providing physicians of their own sex to poor women, by instituting policies that relieved the financial burden on the poor
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during times of illness, or by extending an open hand to single mothers. This was, moreover, the reputation her hospital enjoyed among Boston’s social reformers. The Liberator, which kept its readers apprised of developments at the New England, emphasized the hospital’s ‘‘continued reception of unmarried women needing humane and friendly care in confinement’’ and its focus on
‘‘the relief of sickness which was complicated with poverty and distress.’’∞π Zakr-
zewska, whose deep sense of justice had been honed by years of involvement in the German radical community and the American women’s movement, had created an institution that sought to level the playing field, providing poor women with both the comfort and the care that women of means could take for granted when they became ill or brought children into the world.
. . .
The radicalism of the early years did not last. Indeed, looking back, one can see signs of fracturing almost from the beginning. The greatest problem Zakrzewska faced was the large number of chronically ill individuals turning up at her doorstep. Needing comfort more than medical care, this population posed a serious challenge. As Zakrzewska wrote as early as 1865: ‘‘Providing good homes and care for [the poor and unfortunate] in their hour of need and trial, is not the sole proof of [the hospital’s] necessity; another proof, more striking can be brought forth, namely, that of absolute saving of life, to say nothing of its scientific test and value.’’∞∫ Zakrzewska’s goal of demonstrating the clinical and scientific acumen of women physicians could not, in other words, be put to the test on patients whose ailments were chronic rather than acute. Portraying the New England Hospital as a home for the needy was all well and good, but she also needed patients who required short-term medical and surgical interventions in order to prove her case, for it was their lives that could be saved quickly and heroically.
Early on, then, Zakrzewska came up against the problems inherent in trying to serve two di√erent populations: her patients and her students. Other hospitals that permitted clinical instruction experienced this tension as well, but at least at those hospitals a lay board of trustees usually guarded its role as protector of the patient population, frequently thwarting attempts by the medical sta√
to put pedagogical interests before the well-being of the patients. As a result, the two populations had di√erent authoritative bodies representing their interests. ∞Ω
That was not the case at the New England Hospital, where, despite the existence of a lay board of trustees, Zakrzewska retained most of the decision-making power. She thus struggled to find a balance between the good of her
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students and the good of her patients. As time went on, she tended to favor the former more and more.≤≠
The chronically ill posed another problem above and beyond their slow recovery rates. They also drained financial resources, occupying the limited number of beds for long periods of time, often unable, moreover, to contribute much toward their care. This was a burden the hospital could hardly a√ord.
Although the charity cases in the maternity ward were paid for largely by the Lying-in Hospital Corporation (an association that had funded the Boston Lying-In Hospital during its brief existence in the mid-1850s), for those who needed charitable assistance in the medical or surgical wards, the hospital had to scramble about for donations from year to year.≤∞ In addition, the expansion in 1865 had been expensive, and although the New England had received a five-thousand-dollar matching grant from the Massachusetts legislature, it had encountered di≈culties raising funds for both the match and its operating expenses. As a result of these financial concerns, the hospital ultimately changed its policies toward the poor. First, in the summer of 1866, the board of directors passed a resolution refusing a bed in either the medical or surgical ward to anyone who could not pay the full price of eight dollars a week. Not wishing to make this a permanent measure, it next turned to the dispensary. Thus, in 1868, just a few years after Zakrzewska had refused to scrutinize dispensary patients, the New England Hospital began charging twenty-five cents for each prescription unless an individual could produce a certificate authenticating her poverty.
By the end of the year, Cheney could announce that ‘‘the result has exceeded our expectations’’ and that the fees almost covered all the dispensary’s expenses.
What she did not mention was that this policy also e√ectively reduced the number of individuals seeking help. From a record-breaking 4,576 individuals who were treated in the dispensary in 1867, the numbers dropped to 3,236 in 1868 and to 2,854 in 1869. Zakrzewska, who approved of this new arrangement, insisted at the end of the decade that she no longer wanted to see in the dispensary anyone ‘‘who is not so poor as to have a charity certificate signed.’’≤≤
Zakrzewska never explained her dramatic switch from refusing to humiliate her dispensary patients by insisting on a ‘‘card of introduction’’ to demanding
‘‘a charity certificate.’’ Circumstantial evidence suggests, however, that two factors were probably at play. We have already noted that for Zakrzewska the hospital mattered most as proof that women could manage their own hospital.
As interested as she may have been in the charitable dimension of the institution, she was more committed to the role the institution played in challenging
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table 4. Percentage of Foreign-Born and Irish at the New England’s Dispensary 1863
1864
1865
1866
1867
1868
1869
1870
1871
1872
Foreign
54.1
52.9
55.1
55.1
58.0
61.5
57.6
60.7
60.7
58.4
Irish
26.3
30.5
38.1
40.6
44.1
41.2
45.3
47
44.9
40.9
Sources: Calculated from the New England Hospital’s annual reports for 1863, 1867–72, and from New England Hospital for Women and Children, Records of Patients Who Received Prescriptions [b ms b19.5], 1864–66, Boston Medical Library in the Francis A. Countway Library of Medicine, Boston, Mass.
stereotypes about women’s ability to hold positions of power. As in her autobiographical sketch, gender once again trumped class. Thus when the New England faced the possibility of financial debts, which, she believed, marked
‘‘the commencement of the undermining of an institution,’’ she implemented policies for the good of the institution that resulted in the curtailment of benefits to the poor. Over the decades Zakrzewska would repeatedly relax some of her principles when the survival of her institution was at stake.≤≥
But financial concerns alone did not lead to Zakrzewska’s change of heart.
She also showed signs of growing disillusionment with the women attending the dispensary. Indeed, by the end of the decade, the annual reports no longer portrayed the typical dispensary patient as ‘‘a respectable woman’’ who was
‘‘too proud to ask charity of a physician’’ but rather as someone who needed to be taught how to ‘‘dispel ignorance, promote temperance, banish licentiousness and other vices.’’ Evoking images of the undesirable as unclean and contagious, Zakrzewska even went so far as to blame the dispensary patients, who came
‘‘from the poorest quarters of the city,’’ for adding ‘‘
to the impurity of the atmosphere’’ of the hospital, even though she acknowledged that the two structures were ‘‘almost entirely shut o√ ’’ from each other.≤∂ A look at changes in the dispensary population over the first ten years reveals why this may have been the case. As Table 4 indicates, the population was becoming not only increasingly foreign but also increasingly Irish. One need only remember Zakrzewska’s anti-Catholicism as well as her disparaging remarks about the Irish in her autobiographical sketch to recognize that she harbored little a√ection for this immigrant group.≤∑ It bears mention, as Table 5 shows, that a similar shift in national identity did not take place in the hospital population, which became both less foreign and less Irish as the decade wore on.
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table 5. Percentage of Foreign-Born and Irish at the New England’s Hospital 1863
1864
1865
1866
1867
1868
1869
1870
1871
1872
Foreign
59.3
n.d.
n.d.
n.d.
59.6
54.2
42.4
58.2
55.4
49.4
Irish
33.1
n.d.
n.d.
n.d.
33.3
29.6
18.5
32.2
23.5
23.1
Sources: Calculated from the New England Hospital’s annual reports for 1863, 1867–72, and from New England Hospital for Women and Children, Records of Patients Who Received Prescriptions [b ms b19.5], 1864–66, Boston Medical Library in the Francis A. Countway Library of Medicine, Boston, Mass.
Note: n.d. = no data.
Alongside this growing distaste for the dispensary population, Zakrzewska also began to show an increased interest in attracting a more a∆uent patient population. This shift was evident in the annual reports, which retained the image of the hospital as a home but which began to make it over into a home with middle-class accoutrements. Thus subscribers read about the hospital’s need for more private rooms, a ‘‘patients’ parlor,’’ ‘‘more ground around the house,’’ and, above all, respite from the ‘‘noise and dust and crowded condition of the streets
[which] make our present place quite unfit for nervous chronic patients.’’≤∏ Not
surprisingly, by this time, Zakrzewska and her board of directors had decided that it was in their best interest to move the hospital out of the inner city.
No doubt this decision was spurred on by the New England Hospital’s need for more space. The 1865 renovations had, in fact, proved inadequate almost immediately. But there can be no question that the move was also part and parcel of a drive to attract a di√erent patient population and to create a di√erent image for the hospital. Significantly, there was never any plan to move the dispensary to Roxbury with the hospital.≤π Although this made sense, both because the poor lacked the time and money necessary to take the streetcar out to Roxbury and because the hospital’s interns learned medicine in part by attending to the sick poor in their homes, more was clearly going on. Zakrzewska’s characterization of the dispensary population as carriers of impurities and thus a threat to the salubrity of the hospital patients reveals the dense connections between ideas of cleanliness and contagion and notions of class and ethnicity that historians of disease have long described. ≤∫
In fact, Zakrzewska and her sta√ had been voicing their concerns for years that the noxious airs of the inner city were detrimental to the convalescence of their hospital patients. In doing so, they were embracing a view of disease that
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went virtually uncontested in the days before the germ theory and that imagined disease, and especially infection, to be intimately linked with the environment; bad air, whether emanating from people or places, and not germs per se, could cause an infection to spread out of control through the hospital wards. As a result, standard practices were to increase ventilation through open windows and specific architectural design, as well as to vacate wards where the infections began for purposes of purification.≤Ω Indeed, Zakrzewska explained that much of her motivation for wanting a larger facility was in order to leave some wards
‘‘always in reserve for change and purification, thus fulfilling all the hygienic laws demanded by hospital life.’’ Writing this in 1869, she estimated that the New England Hospital had two years before its current conditions would be considered ‘‘not merely undesirable, but really injurious to the health of all, both patients and o≈cers.’’≥≠
Zakrzewska, however, did not simply want more room; she also wanted to move the hospital out of the inner city and thus as far away as possible from the individuals who frequented the dispensary and made the already bad air cours-ing through the hospital even worse. Her desire for a ‘‘better’’ class of patients surely reflected both her hope for more revenue and her conviction that individuals of means had a better chance of recovering from a serious illness.≥∞ What better way, after all, to convince the world that women physicians should be encouraged to practice medicine than to sit at the helm of a hospital whose rates of cure surpassed those of comparable institutions? Indeed, an intern who studied at the hospital later in the century accused the institution of turning away seriously ill patients because their deaths ‘‘would make the Hospital report look badly.’’≥≤ But Zakrzewska’s increased indi√erence toward the plight of the poorest of the poor, among whom the Irish were well represented, also reveals the limits of her radicalism and her growing willingness to accept, for at least certain populations, the tight links between poverty, filth, contagion, and ethnicity that flourished in her day.
Zakrzewska’s pleas for a new hospital were heard, and adequate funds were raised to start construction. By September 1872 the new premises were ready to be occupied. Located on Codman Avenue in Roxbury, the New England Hospital now had the ‘‘benefit of country air and quiet.’’ With a capacity of ninety beds—fifty-seven for the patients and another thirty-three for nurses, students, and other sta√—the hospital had more than doubled its occupancy. Twenty-three of the beds were in the medical ward, another twelve in the surgical ward, and another six earmarked specifically for children. The remaining twenty pa-
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New England Hospital for Women and Children. (Courtesy of
Sophia Smith Collection, Smith College)
tient beds (twelve for mothers and another eight cribs for infants) were housed in a separate maternity cottage on the premises. The 1872 annual report drew particular attention to the hospital’s new physical arrangement, which allowed it to prevent the spread of infection to parturient women. It also advertised the
‘‘light, airy, sunny wards’’ found throughout the main building and the presence of a ‘‘pleasant Patients’ Parlor’’ on the west side of the building. (In subsequent years, the annual reports also conveyed news about piano recitals and carriage rides.) Finally, it mentioned the addition of a few private rooms on the first floor for those women ‘‘whose means enabled them to pay for superior accommodations.’’ Anyone paying twenty-five dollars a week had the benefit of ‘‘a nurse exclusively devoted to her,—board, medical attendance, and washing.’’ According to Emma Call, who joined the medical sta√ in 1875, the changes brought about the desired e√ects, with the result that ‘‘the class of patients was . . . a much better one,’’ no longer including ‘‘any considerable number of the most undesirable cases, which inevitably gravitate to an institution located in the midst of a dense population.’’ The institution certainly still catered to the sick poor, but it had taken a big step toward assuring that ‘‘the moderately well to do’’ would also find a home within
its walls.≥≥
. . .
Patient information for the years following the New England Hospital’s move to Roxbury is rich compared with the data available for the first decade of the
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table 6. Percentage of Charity Cases at the New England, the Boston Lying-In, and Massachusetts General, 1877–1886
1877
1878
1879
1880
1881
1882
1883
1884
1885
1886
Avg
neh
57.2
54.2
55.5
54.1
45.1
34.6
25.6
41.5
39.9
47.2
45.5
bli
71.8
68.5
76.1
80.2
70.6
66.4
61.8
56.2
70.3
74
69.6
mgh
83.1
82.0
82.9
81.7
72
n.d.
72.4
80.6
84.7
84.2
80.4
Sources: Calculated from the annual reports of the New England Hospital, the Boston Lying-In Hospital, and Massachusetts General Hospital. See also Bowditch, History of the Massachusetts General Hospital, 702, and Vogel, ‘‘Patrons, Practitioners, and Patients,’’ 290.
Notes: The data for Massachusetts General Hospital are for its female patients alone.
For 1877 and 1878, the New England Hospital provided joint statistics for those who paid nothing and those who paid part board. To derive an estimate of the number who paid absolutely nothing (necessary in order to make a comparison with the other hospitals), I calculated the relationship between full charity and part charity for 1879, 1880, and 1881; took the average of the three (which was 72.33 percent for full charity, compared with 27.66 percent for part); and used that to estimate the number of full charity cases for 1877 and 1878.
neh = New England Hospital; bli = Boston Lying-In Hospital; mgh = Massachusetts General Hospital; n.d. = no data.